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. 2021 Sep 1;4(9):e2123471.
doi: 10.1001/jamanetworkopen.2021.23471.

Sociodemographic, Clinical, and Treatment-Related Factors Associated With Hyperglycemic Crises Among Adults With Type 1 or Type 2 Diabetes in the US From 2014 to 2020

Rozalina G McCoy  1   2 , Rodolfo J Galindo  3 , Kavya Sindhu Swarna  2 , Holly K Van Houten  2   4 , Patrick J O'Connor  4 , Guillermo E Umpierrez  3 , Nilay D Shah  2   5
Affiliations

Sociodemographic, Clinical, and Treatment-Related Factors Associated With Hyperglycemic Crises Among Adults With Type 1 or Type 2 Diabetes in the US From 2014 to 2020

Rozalina G McCoy et al. JAMA Netw Open. .

Abstract

Importance: Hyperglycemic crises (ie, diabetic ketoacidosis [DKA] and hyperglycemic hyperosmolar state [HHS]) are life-threatening acute complications of diabetes. Efforts to prevent these events at the population level have been hindered by scarce granular data and difficulty in identifying individuals at highest risk.

Objective: To assess sociodemographic, clinical, and treatment-related factors associated with hyperglycemic crises in adults with type 1 or type 2 diabetes in the US from 2014 to 2020.

Design, setting, and participants: This retrospective cohort study analyzed administrative claims and laboratory results for adults (aged ≥18 years) with type 1 or type 2 diabetes from the OptumLabs Data Warehouse from January 1, 2014, through December 31, 2020.

Main outcomes and measures: Rates of emergency department or hospital visits with a primary diagnosis of DKA or HHS (adjusted for age, sex, race/ethnicity, and region, and for year when calculating annualized rates) were calculated separately for patients with type 1 diabetes and type 2 diabetes. The associations of sociodemographic factors (age, sex, race/ethnicity, region, and income), clinical factors (comorbidities), and treatment factors (glucose-lowering medications, hemoglobin A1c) with DKA or HHS in patients with type 1 or type 2 diabetes were assessed using negative binomial regression.

Results: Among 20 156 adults with type 1 diabetes (mean [SD] age, 46.6 [16.5] years; 51.2% male; 72.6% White race/ethnicity) and 796 382 with type 2 diabetes (mean [SD] age, 65.6 [11.8] years; 50.3% female; 54.4% White race/ethnicity), adjusted rates of hyperglycemic crises were 52.69 per 1000 person-years (95% CI, 48.26-57.12 per 1000 person-years) for type 1 diabetes and 4.04 per 1000 person-years (95% CI, 3.88-4.21 per 1000 person-years) for type 2 diabetes. In both groups, factors associated with the greatest hyperglycemic crisis risk were low income (≥$200 000 vs <$40 000: type 1 diabetes incidence risk ratio [IRR], 0.61 [95% CI, 0.46-0.81]; type 2 diabetes IRR, 0.69 [95% CI, 0.56-0.86]), Black race/ethnicity (vs White race/ethnicity: type 1 diabetes IRR, 1.33 [95% CI, 1.01-1.74]; type 2 diabetes IRR, 1.18 [95% CI, 1.09-1.27]), high hemoglobin A1c level (≥10% vs 6.5%-6.9%: type 1 diabetes IRR, 7.81 [95% CI, 5.78-10.54]; type 2 diabetes IRR, 7.06 [95% CI, 6.26-7.96]), history of hyperglycemic crises (type 1 diabetes IRR, 7.88 [95% CI, 6.06-9.99]; type 2 diabetes IRR, 17.51 [95% CI, 15.07-20.34]), severe hypoglycemia (type 1 diabetes IRR, 2.77 [95% CI, 2.15-3.56]; type 2 diabetes IRR, 4.18 [95% CI, 3.58-4.87]), depression (type 1 diabetes IRR, 1.62 [95% CI, 1.37-1.92]; type 2 diabetes IRR, 1.46 [95% CI, 1.34-1.59]), neuropathy (type 1 diabetes IRR, 1.64 [95% CI, 1.39-1.93]; type 2 diabetes IRR, 1.25 [95% CI, 1.17-1.34]), and nephropathy (type 1 diabetes IRR, 1.22 [95% CI, 1.01-1.48]; type 2 diabetes IRR, 1.23 [95% CI, 1.14-1.33]). Age had a U-shaped association with hyperglycemic crisis risk in patients with type 1 diabetes (compared with patients aged 18-44 years: 45-64 years IRR, 0.72 [95% CI, 0.59-0.87]; 65-74 years IRR, 0.62 [95% CI, 0.47-0.80]; ≥75 years IRR, 0.96 [95% CI, 0.66-1.38]). In type 2 diabetes, risk of hyperglycemic crises decreased progressively with age (45-64 years IRR, 0.57 [95% CI, 0.51-0.63]; 65-74 years IRR, 0.44 [95% CI, .39-0.49]; ≥75 years IRR, 0.41 [95% CI, 0.36-0.47]). In patients with type 2 diabetes, higher risk was associated with sodium-glucose cotransporter 2 inhibitor therapy (IRR, 1.30; 95% CI, 1.14-1.49) and insulin dependency (compared with regimens with bolus insulin: regimens with basal insulin only, IRR, 0.69 [95% CI, 0.63-0.75]; and without any insulin, IRR, 0.36 [95% CI, 0.33-0.40]).

Conclusions and relevance: In this cohort study, younger age, Black race/ethnicity, low income, and poor glycemic control were associated with an increased risk of hyperglycemic crises. The findings suggest that multidisciplinary interventions focusing on groups at high risk for hyperglycemic crises are needed to prevent these dangerous events.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr McCoy reported receiving an AARP Quality Measure Innovation Grant from the AARP and grants from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Mayo Clinic outside the submitted work. Dr Galindo reported receiving grants from the NIDDK and Novo Nordisk and Dexcom (to Emory University) and receiving personal fees from Abbott Diabetes Care, Eli Lilly and Company, Novo Nordisk, Sanofi, and Valeritas. Dr O’Connor reported receiving grants from the National Heart, Lung and Blood Institute, the NIDDK, the Patient Centered Outcomes Research Institute, the National Cancer Institute, and the National Institute on Drug Abuse. Dr Umpierrez reported receiving grants from the National Center for Advancing Translational Sciences and receiving unrestricted research support from AstraZeneca, Novo Nordisk, and Dexcom (to Emory University). Dr Shah reported receiving research support (through Mayo Clinic) from the US Food and Drug Administration and the Centers of Medicare and Medicaid Innovation and receiving grants from the Agency for Healthcare Research and Quality, the National Heart, Lung and Blood Institute, the National Science Foundation, and the Patient Centered Outcomes Research Institute. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Adjusted Rates of Hyperglycemic Crises Among Adults With Type 1 Diabetes Stratified by Age, Sex, Race/Ethnicity, Annual Household Income, and Year
All rates are adjusted for age (age at index for all analyses except for annual rates, which used age at the time of the event), sex, race/ethnicity, US region, and year (for annualized rates). For age, P < .001; sex, P < .001; race/ethnicity, P = .002; annual household income, P < .001; and year, P = .01.
Figure 2.
Figure 2.. Adjusted Rates of Hyperglycemic Crises Among Adults With Type 2 Diabetes Stratified by Age, Sex, Race/Ethnicity, Annual Household Income, Insulin Therapy, and Year
All rates are adjusted for age (age at index for all analyses except for annual rates, which used age at the time of the event), sex, race/ethnicity, US region, and year (for annualized rates). For age, P < .001; sex, P < .001; race/ethnicity, P < .001; annual household income, P < .001; insulin requirement, P < .001; and year, P = .16.
See this image and copyright information in PMC

References

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